Surgical Constructs with Collapsing Suture Loop and Methods for Securing Tissue

ABSTRACT

Surgical constructs and methods are provided for securing soft tissue to bone. One exemplary embodiment of a construct is formed from a suture filament and includes two terminal ends of filament and an intermediate portion disposed along at least a portion of a length extending between the terminal ends. The construct can have a first terminal end that is the first terminal end of the filament, and a second terminal end that includes a loop. The loop can be formed by disposing the second terminal end of the filament within a volume of a portion of the intermediate portion of the filament. In some disclosed methods, both terminal ends of the filament can be passed through tissue when performing soft tissue repairs. Various other embodiments of constructs and methods are provided, including constructs having two or more filaments associated with an anchor and methods of using such constructs.

PRIORITY

The present application is a continuation of and claims priority to U.S.patent application Ser. No. 15/648,068, filed Jul. 12, 2017, andentitled “Surgical Constructs with Collapsing Suture Loop and Methodsfor Securing Tissue,” which is a divisional of and claims priority toU.S. patent application Ser. No. 14/145,486, filed Dec. 31, 2013, andentitled “Surgical Constructs with Collapsing Suture Loop and Methodsfor Securing Tissue,” and which issued as U.S. Pat. No. 9,737,293 onAug. 22, 2017, which claims priority to and the benefit of U.S.Provisional Application No. 61/791,079, filed on Mar. 15, 2013, andentitled “Suture Anchor System with Collapsing Suture Loop,” thecontents of each of which is hereby incorporated by reference in theirentireties.

FIELD

The present disclosure relates to surgical constructs and methods forsecuring soft tissue to bone, and more particularly relates to surgicalconstructs having a collapsing suture loop.

BACKGROUND

A common injury, especially among athletes and people of advancing age,is the complete or partial detachment of tendons, ligaments, or othersoft tissues from bone. Tissue detachment may occur during a fall, byoverexertion, or for a variety of other reasons. Surgical interventionis often needed, particularly when tissue is completely detached fromits associated bone. Currently available devices for tissue attachmentinclude screws, staples, suture anchors, and tacks. Currently availabledevices for patients of advancing age can be particularly insufficientdue to soft and weak bones leading to inadequate fixation between theanchor and bones and the anchors and filaments with which the anchorsare coupled.

Repair constructs made from one or more surgical filaments are typicallyused in soft tissue repair procedures to secure the tissue in a desiredlocation. The repair constructs are typically disposed through one ormore portions of the tissue to be repaired, which can cause trauma tothe tissue, and are often coupled to anchors disposed in bone to whichthe tissue is to be approximated. While devices and techniques have beendeveloped to help minimize trauma associated with passing repairconstructs through tissue, there is still room for further improvement.For example, some repair constructs may include a sleeve disposed aroundat least a portion of the limbs of filament of the construct. The sleevecan assist in minimizing trauma to tissue, and also in managing thelimbs of suture while the construct is being disposed through tissue.However, the sleeve still adds extra size above and beyond the thicknessof the suture, and thus can be a source for added trauma to the tissue.Sleeves also add further costs to the constructs.

In other instances, sutures used in repairs can have portions that havea thicker profile, for instance because they have extra loops, knots, orother configurations formed therein as part of the construct. Thickerprofiles can, not surprisingly, provide additional sources of trauma forthe tissue as these portions of the construct pass through the tissue.As a result, procedures can often include extra steps to avoid passingportions of the construct that have thicker profiles through tissue. Forexample, in some instances, a shuttle suture is used to pull theconstruct through tissue so that an end with a thicker profile does nothave to be passed through tissue. The use of additional components, suchas a shuttle suture, however, can be cumbersome. Further, to generallyavoid trauma to tissue, some procedures may only involving passing aconstruct through tissue one time. This approach, however, can lead tounsecure tissue attachments due to the footprint of the constructholding the tissue not being large enough.

Still further, there remains a desire to minimize the number of knotsused in conjunction with the repair construct when performing softtissue repair procedures. A variety of different knots, such as slidingknots, can be used to help draw and secure soft tissue with respect tobone. Although the tying of knots at a surgical site is common, in someinstances knots can have a tendency to slip, which in turn can cause aloss of tension between the tissue and bone. This drawback is sometimesreferred to as a loss of “loop security.” In addition to this “loopsecurity” issue, conventional knots typically have an overall size thatcan be obstructive or intrusive, especially in tight joints, which maydamage cartilage or other tissue by abrasion with the knot.

It is therefore desirable to provide repair constructs and methods thatreduce the amount of trauma associated with using repair constructswhile maintaining or improving the holding strength such constructs andmethods can provide. It is also desirable to provide surgical repairmethods that reduce the number of steps performed without losing theintegrity of the repair performed. Further, it is desirable to provideconstructs and methods for use in soft tissue repair that minimize oreliminate the number and size of knots to be tied by a surgeon,particularly during arthroscopic repair procedures.

SUMMARY

Surgical constructs and methods are generally provided for securing softtissue to bone. In one exemplary embodiment, the surgical construct isformed from a suture filament and includes a first terminal end of thefilament, a second terminal end of the filament, and an intermediateportion of the filament disposed along at least a portion of a lengthextending between the first and second terminal ends. The construct canfurther include a coaxial region formed by the first terminal end beingdisposed within a volume of a portion of the intermediate portion, and acontinuous, closed loop extending from a first side of the coaxialregion. The loop can have a first end that is directly adjacent to thefirst side of the coaxial region, and a second, opposed end formed by afold in the suture filament. The second, opposed end of the loop can bea first terminal end of the construct, while the second terminal of thefilament can extend from a second side of the coaxial region and be asecond terminal end of the construct.

A length of the loop of the construct can be configured to be adjustedby moving the first terminal end of the filament with respect to thecoaxial region. The construct itself can have a variety ofconfigurations and sizes. By way of non-limiting examples, in someembodiments a length of the coaxial region can be at least about 15.24centimeters. Likewise, in some embodiments a length of the loop can beat least about 20.32 centimeters. A pick count of the coaxial region canbe in a range of about 30 picks per 2.54 centimeters to about 60 picksper 2.54 centimeters. In one exemplary embodiment the pick count of thecoaxial region is approximately 40 picks per 2.54 centimeters. In someembodiments, the construct can include an anchor having a filamentengagement feature at a distal end thereof. The suture filament canengage th filament engagement feature such that the first terminal endof the construct extends from one side of the filament engagementfeature and the second terminal end of the construct extends from anopposite side of the filament engagement feature.

One exemplary embodiment of a surgical repair method includes insertingan anchor in bone and in proximity to detached soft tissue. The anchorcan have a surgical filament associated therewith, with the filamenthaving a first portion with a loop formed therein, a second portion thatincludes a terminal end, and a coaxial region formed between the firstand second portions by disposing a portion of the filament into its ownvolume. The method can include passing the terminal end of the secondportion of the filament through a portion of the detached soft tissue,forming a snare in the loop of the first portion of the filament afterthe anchor has been inserted in bone in proximity to detached softtissue, and passing the terminal end of the second portion through thesnare. The snare can be collapsed to engage the soft tissue and advanceddistally to bring the tissue into proximity with the bone. The coaxialregion can be deconstructed by removing the portion of the filament fromthe volume of the filament in which it was disposed.

Another step that can be provided as part of the method includes passingthe loop through a portion of the detached soft tissue before formingthe snare in the loop. Further, in some instances the method can includetying at least one locking knot with the filament at a location that isproximate to the collapsed snare to secure a location of the filamentwith respect to the tissue.

In some embodiments the anchor can have a second surgical filamentassociated with it. The second filament can include a first portion witha loop formed therefrom, a second portion that includes a terminal end,and a coaxial region formed between the first and second portions bydisposing a portion of the filament into its own volume. In such anembodiment, the method can further include passing the terminal end ofthe second portion of the second filament through a portion of thedetached soft tissue and passing the loop of the second filament througha portion of the detached soft tissue. After the loop has been passedthrough the tissue, a snare can be formed in that loop. The terminal endof the second portion of the second filament can be passed through thesnare of the second filament, the snare can be collapsed to engage thesoft tissue, and then the collapsed snare can be advanced distally tobring the tissue into proximity with the bone. The coaxial region of thesecond filament can be deconstructed by removing the portion of thesecond filament from the volume of the second filament in which it wasdisposed. Deconstructing the coaxial regions of the first and secondfilaments can result in a first limb and a second limb extending fromtheir respective collapsed snares. The first and second limbs of bothfilaments can then be attached to a second anchor, and tension can beapplied to the limbs to secure a location of the same with respect tothe second anchor. For example, tension can be applied by inserting thesecond anchor into bone with the first and second limbs being disposedbetween an outer wall of the anchor and the bone. In some embodiments,the locations of the first and second limbs of the filaments withrespect to the second anchor can be secured without tying a knot ineither of the first or second filaments.

In another embodiment in which a second surgical filament is provided,the filament can have a first portion with a snare formed therein, asecond portion that includes a terminal end, and a coaxial region formedbetween the first and second portions by disposing a portion of thefilament into its own volume. The snare in the first portion can bepre-existing, or alternatively, it can be formed in the construct atsome point during the procedure. In addition to using the first filamentas described earlier, the method can further include passing theterminal end of the second portion of the second filament through aportion of the detached soft tissue and passing the first portion of thesecond filament through an opening extending through a length of theanchor. The terminal end of the second filament can be passed throughthe snare of the second filament, the snare can be collapsed to engagethe soft tissue, and then the collapsed snare can be advanced distallyto bring the tissue into proximity with the bone. As a result, the firstfilament can be disposed between the collapsed snare of the secondfilament and the soft tissue.

Another exemplary embodiment of a surgical repair method includesinserting an anchor in bone in proximity to detached soft tissue. Theanchor can have a surgical construct associated therewith, with theconstruct having a first terminal end and a second terminal end. Themethod can include passing the first terminal end through a portion ofthe detached soft tissue, passing the second terminal end through aportion of the detached soft tissue, and then subsequently forming aLark's Head cinch loop in the second terminal end of the surgicalconstruct such that the Lark's Head cinch loop defines a receivingopening. The first terminal end of the construct can be passed throughthe receiving opening, the receiving opening can be collapsed, and thecollapsed Lark's Head cinch loop can be advanced distally to bring thetissue into proximity with the bone.

The surgical construct can be formed from a surgical filament having afirst terminal end, a second terminal end, and an intermediate portionextending therebetween, with the first terminal end of the constructbeing the first terminal end of the filament, and the second terminalend of the construct having a loop formed by the second terminal end ofthe filament being disposed in a portion of the intermediate portion ofthe filament. The method can further include removing the secondterminal end of the filament from the intermediate portion of thefilament after collapsing the receiving opening of the Lark's Head cinchloop, and tying at least one knot with the filament at a location thatis proximate to the collapsed Lark's Head cinch loop to secure alocation of the filament with respect to the tissue.

In some embodiments, the anchor can have a second surgical constructassociated therewith. The second construct can be formed from a secondsurgical filament having a first terminal end, a second terminal end,and an intermediate portion extending therebetween. A first terminal endof the second construct can be the first terminal end of the secondfilament, and a second terminal end of the second construct can have aloop formed by the second terminal end of the second filament beingdisposed in a portion of the intermediate portion of the secondfilament. In addition to using the first construct as described earlier,the method can further include passing the terminal end of the secondconstruct through a portion of the detached soft tissue and passing thesecond terminal end of the second construct through a portion of thedetached soft tissue. After the first and second terminal ends of thesecond construct have been passed through portions of the detachedtissue, a Lark's Head cinch loop can be formed in the second terminalend of the second construct, with the knot defining a receiving opening.The first terminal end of the second construct can be passed through thereceiving opening of the second construct, the opening can be collapsed,and then the collapsed Lark's Head cinch loop can be advanced distallyto bring the tissue into proximity with the bone. After collapsing thereceiving opening of the Lark's Head cinch loop, the method can furtherinclude removing the second terminal end of the first filament from theintermediate portion of the first filament and removing the secondterminal end of the second filament from the intermediate portion of thesecond filament to provide first and second limbs of each of the firstand second filaments extending from the respective collapsed Lark's Headcinch loops. The first and second limbs of both filaments can then beattached to a second anchor, and tension can be applied to the limbs tosecure a location of the same with respect to the second anchor. Forexample, tension can be applied by inserting the second anchor into bonewith the first and second limbs being disposed between an outer wall ofthe anchor and the bone. In some embodiments, the locations of the firstand second limbs of the filaments with respect to the second anchor canbe secured without tying a knot in either of the first or secondfilaments.

In another embodiment in which a second surgical construct is associatedwith the anchor, the construct can include a first terminal end and asecond terminal end, the second terminal end having a snare formedtherein. The snare in the second terminal end can be pre-existing, oralternatively, it can be formed in the construct at some point duringthe procedure. In addition to using the first construct as describedearlier, the method can further include passing the first terminal endof the second construct through a portion of the detached tissue andpassing the second terminal end of the second construct through anopening extending through a length of the anchor. The first terminal endof the second construct can be passed through the snare of the secondconstruct, the snare can be collapsed, and then the collapsed snare canbe advanced distally to bring the tissue into proximity with the bone.As a result, the first construct can be disposed between the collapsedsnare of the second construct and the soft tissue.

BRIEF DESCRIPTION OF DRAWINGS

This invention will be more fully understood from the following detaileddescription taken in conjunction with the accompanying drawings, inwhich:

FIG. 1A is a schematic view of one exemplary embodiment of a surgicalrepair construct formed from a suture filament;

FIG. 1B is a detail view of a coaxial region of the surgical repairconstruct of FIG. 1A;

FIG. 2 is a schematic view of the surgical repair construct of FIG. 1Acoupled to a suture anchor;

FIG. 3A is a schematic view of another exemplary embodiment of asurgical repair construct, the construct being formed from two separatesuture filaments, each filament having the configuration of the filamentof the repair construct of FIG. 1A, and each filament being coupled to asuture anchor;

FIG. 3B is a schematic view of still another exemplary embodiment of asurgical repair construct, the construct being formed from threeseparate suture filaments, each filament having the configuration of thefilament of the repair construct of FIG. 1A, and each filament beingcoupled to the suture anchor of FIG. 3A;

FIGS. 4A-4N are sequential, schematic, cross-sectional views of oneexemplary embodiment for using the surgical repair construct of FIG. 2to secure tissue to bone;

FIG. 5A is a schematic, cross-sectional view of an alternative step thatcan be performed in place of the step illustrated in FIG. 4N;

FIG. 5B is a schematic, top view of the alternative step of FIG. 5Aperformed in conjunction with using the construct of FIG. 3A;

FIGS. 6A-6C are sequential, schematic views of one exemplary embodimentfor forming a Lark's head cinch loop as used in the step illustrated inFIG. 4H;

FIGS. 7A-7F are sequential, schematic, cross-sectional views of oneexemplary embodiment for using the surgical repair construct of FIG. 1to secure tissue to bone, with FIG. 7C illustrating an alternativeconfiguration of the construct to FIG. 7B;

FIG. 8 is a schematic, top view of another exemplary embodiment forusing the surgical repair construct of FIG. 1 to secure tissue to bone;

FIG. 9 is a schematic, top view of one exemplary embodiment for usingthe surgical repair construct of FIG. 3A to secure tissue to bone;

FIG. 10 is a schematic, top view of one exemplary embodiment for usingthe surgical repair construct of FIG. 2;

FIG. 11 is a schematic, top view of still another exemplary embodimentfor using the surgical repair construct of FIG. 2;

FIG. 12 is a schematic, top view of yet another exemplary embodiment forusing the surgical repair construct of FIG. 2;

FIG. 13 is a schematic, top view of one exemplary embodiment for usingthe surgical repair construct of FIG. 3B;

FIG. 14 is a schematic, top view of one exemplary embodiment for usingthe surgical repair construct of FIG. 1A in conjunction with thesurgical repair construct of FIG. 2; and

FIG. 15 is a schematic, side view of another exemplary embodiment forusing the surgical repair construct of FIG. 3A.

DETAILED DESCRIPTION

Certain exemplary embodiments will now be described to provide anoverall understanding of the principles of the structure, function,manufacture, and use of the devices and methods disclosed herein. One ormore examples of these embodiments are illustrated in the accompanyingdrawings. Those skilled in the art will understand that the devices andmethods specifically described herein and illustrated in theaccompanying drawings are non-limiting exemplary embodiments and thatthe scope of the present invention is defined solely by the claims. Thefeatures illustrated or described in connection with one exemplaryembodiment may be combined with the features of other embodiments. Suchmodifications and variations are intended to be included within thescope of the present invention. Additionally, to the extent that linearor circular dimensions are used in the description of the disclosedconstructs and methods, such dimensions are not intended to limit thetypes of shapes that can be used in conjunction with such constructs andmethods. A person skilled in the art will recognize that an equivalentto such linear and circular dimensions can easily be determined for anygeometric shape. Sizes and shapes of the constructs, and the componentsthereof, can depend at least on the anatomy of the subject in which theconstructs will be used, the size and shape of components with which theconstructs will be used, and the methods and procedures in which theconstructs will be used.

The figures provided herein are not necessarily to scale. Further, tothe extent arrows are used to describe a direction a component can betensioned or pulled, these arrows are illustrative and in no way limitthe direction the respective component can be tensioned or pulled. Aperson skilled in the art will recognize other ways and directions forcreating the desired tension or movement. Likewise, while in someembodiments movement of one component is described with respect toanother, a person skilled in the art will recognize that other movementsare possible. Additionally, although terms such as “first” and “second”are used to describe various aspects of a component, e.g., a first endand a second end, such use is not indicative that one component comesbefore the other. Use of terms of this nature may be used to distinguishtwo similar components or features, and often such first and secondcomponents can be used interchangeably. Still further, a number of termsmay be used throughout the disclosure interchangeably but will beunderstood by a person skilled in the art. By way of non-limitingexample, the terms “suture” and “filament” may be used interchangeably.

Surgical repair constructs and methods for soft tissue repair aregenerally provided and they generally involve the use of surgicalfilaments that are configured in a variety of manners to minimize and/oreliminate the tying of knots during a surgical procedure while alsominimizing the amount of trauma imparted by the constructs to tissuewith which the constructs are used. The constructs described hereinprovide superior strength for use in a number of different surgicalprocedures, such as rotator cuff and instability repair procedures andother types of tendon and tissue repair procedures. The designs of theconstructs described herein are such that they have a particularly lowprofile, thereby allowing both terminal ends of a construct to passthrough the tissue with minimal trauma to the tissue and to becomeassociated with the tissue without tying knots. The low profile resultsfrom inserting one limb of filament into another and eliminating anysort of sleeve, which is often used to assist in shuttling limbs offilament through tissue. The ability to pass both terminal ends of theconstruct through tissue with minimal trauma to the tissue results fromthe aforementioned low profile configuration and because the disclosedconstructs are generally configured to have one terminal end that is asingle filament and a second terminal end that is a loop in whichopposed portions of the loop each are formed of a single filament.Passing a single filament, or two single filaments as part of a loop,through tissue results in minimal trauma to the tissue.

As shown by one exemplary embodiment of a surgical repair construct 10in FIG. 1A, the construct 10 can generally be formed from a singleelongate filament 20, which is used in the formation of three distinctportions of the construct 10: a loop 12, a coaxial region 14, and a tail16. The filament 20 includes two terminal ends 20 a, 20 b with anintermediate portion extending therebetween. The first terminal end 20 acan also be a terminal end 10 a of the construct 10. Thus, as shown, thefirst terminal end 20 a is part of the tail 16. The second terminal end20 b, which is illustrated in FIG. 1B, can be part of the coaxial region14 formed in an intermediate portion of the construct 10. Moreparticularly, as shown, the second terminal end 20 b passes through anopening 22 of an outer surface of the intermediate portion of thefilament 20 to form a loop closure 24, and then extends into a volume ofthe filament 20. The opening 22 can be manually formed in the filament20, for instance by puncturing it, or it can be an opening that forms aspart of a braided configuration.

At least a portion of the volume of the filament 20 can be hollow toreceive the terminal end 20 b. In some instances, the entire volume ofthe filament 20 can be hollow. This can be achieved, for example byremoving a core from the entire length of the filament 20 usingtechniques known to those skilled in the art. In other embodiments, onlya portion of the core is removed, such as the portion in which theterminal end 20 b will be disposed. Still further, in other embodimentsno core may be removed such that the second terminal end 20 b and thecore are both disposed within the volume of the filament 20.Alternatively, or in addition to, in instances in which the filament 20is a braided filament, the portion of the filament 20 configured to bethe volume that receives the terminal end 20 b to form the coaxialregion 14 can have a reduced pick count. Reducing the pick count canprovide for additional flexibility, and thus additional volume, toreceive the terminal end 20 b.

The loop closure 24 can be a self-maintaining junction. As a result,pulling on the tail 16 does not cause the terminal end 20 b to pull outof the volume of the filament 20 in which it is disposed. Rather,pulling on the tail 16 can actually force the volume of the filament 20to collapse around the terminal end 20 b, thereby providing sufficientfriction between the terminal end 20 b and the filament 20 to hold themtogether. The terminal end 20 b, however, can be removed from the volumemanually at the opening 22 by applying a sufficient amount of force.

Although in the illustrated embodiment the loop closure 24 is formed byinserting the second terminal end 20 b into a volume of the filament 20,a person skilled in the art will understand other ways by which thisjunction can be formed without departing from the spirit of the presentdisclosure. By way of non-limiting examples, the terminal end 20 b canbe adhered to the filament 20, passed from one side of the filament 20through to the other side, or it can be wrapped around the filament 20and held in place by one or more features known to those skilled in theart. For instance, a removable pin or flexible member can be passedacross the terminal end 20 b and a portion of the filament 20 thatserves as the coaxial region 14 to maintain the location of the terminalend 20 b with respect to other portion of the filament 20. When the pinis removed, the terminal end 20 b can then be moved with respect to theportion of the filament 20 that serves as the coaxial region 14.Additional disclosures related to such a pin or flexible member areprovided in U.S. Patent Application Publication No. 2013/0296931, thecontent of which is incorporated herein by reference in its entirety.

The second terminal end 20 b is not only a part of the coaxial region,but it also helps define a length a of the loop 12. The loop 12 can be acontinuous, closed loop configured to have an adjustable length. Moreparticularly, the second terminal end 20 b can be configured to movewith respect to the volume in which it is disposed to adjust the lengtha of the loop 12. As shown in FIG. 1A, the loop 12 is generally definedas having a first end 12 a that is directly adjacent to a second side 14b of the coaxial region 14 and a second end 12 b that is formed by afold 20 f in the suture filament 20, the second end 12 b also doublingas the terminal end 10 b of the construct 10. The continuous, closedloop 12 can be adjustable such that moving the terminal end 20 b withrespect to the volume in which it is disposed can change the length a ofthe loop 12. As shown, applying a force in a direction A can decrease alength a of the loop 12, and moving the second terminal end 20 b out ofthe opening 22 can increase the length a of the loop 12. As describedherein, the loop 12 can have a small profile allowing it to be easilypassed through tissue while causing a minimal amount of trauma to thetissue.

A first side 14 a of the coaxial region can have the tail 16 extendingtherefrom. The tail 16 can extend away from the coaxial region 14 andcan be used in conjunction with the loop 12 to help both draw softtissue towards bone and subsequently maintain the location of the tissuewith respect to the bone. As shown in FIG. 1B, a transition 15 betweenthe second side 14 b and the tail 16 is smooth once the terminal end 20b is not disposed any further in the volume of the filament 20. Thethickness of the filament 20 becomes reduced due to the fact that noother portion of the filament is disposed in the tail 16. The smoothnature of the transition 15 makes it easier to pass the filament 20through tissue.

The construct 10 configuration illustrated in FIGS. 1A and 1B provides anumber of benefits, at least due in part to the second terminal end 20 bbeing disposed in a volume of an intermediate portion of the filament20. For example, the configuration helps with suture management becauseby disposing an end of the filament within another portion of thefilament, it is one fewer end for which a surgeon needs to account. Thisis particularly useful in embodiments in which multiple constructs aredisposed on a single anchor, as described further below, because eachconstruct has multiple ends for which to account. The disclosedconfiguration essentially halves the number of filament ends to manage.The configuration also helps prevent filament tangling. The terminal end20 b cannot tangle with other portions of the filament 20, or othercomponents being used as part of a procedure, when it is disposed withinthe volume of the filament 20. A further benefit that results from theconfiguration is that it affords surgeons better visibility. There arefewer filaments ends that can be in the surgeon's field of view when theterminal end 20 b is disposed within the volume of the filament 20.Still further, because no additional components are used to help achievethese benefits, this configuration provides a cheap and easy way to passfilaments through tissue, while also taking up a minimal amount ofspace.

The filament 20 used to form the construct 10 can be any type andmaterial typically used as filament, including a cannulated filament, abraided filament, and a mono filament. The type and strength of thefilament can depend, at least in part, on the other components withwhich the construct is used, such as an anchor, the tissue through whichit will be passed or coupled to, and the type of procedure in which itis used. In some embodiments the filament can have a size between abouta #5 filament (about 20 gauge to about 21 gauge) and about a #5-0filament (about 35 gauge to about 38 gauge), and in one exemplaryembodiment the filament is a #2 filament (about 22 gauge to about 24gauge), such as an Orthocord™ filament that is commercially availablefrom DePuy Mitek, Inc., DePuy Mitek Inc., 325 Paramount Drive, Raynham,Mass. 02767, or an Ethibond™ filament that is commercially availablefrom Ethicon, Inc., Route 22 West, Somerville, N.J. 08876.

The thickness of the filament should provide strength in the connectionbut at the same time minimize the trauma caused to tissue through whichit passes. In some embodiment, different portions of the construct 10can have different thicknesses, with the thickness being based, at leastin part, on the purpose for that portion, the thicknesses of the otherportions of the construct, the components or tissue through which thatportion may be passed, and the type of procedure in which the constructis used. Orthocord™ suture is approximately fifty-five to sixty-fivepercent PDS™ polydioxanone, which is bioabsorbable, and the remainingthirty-five to forty-five percent ultra high molecular weightpolyethylene, while Ethibond™ suture is primarily high strengthpolyester. The amount and type of bioabsorbable material, if any,utilized in the filaments of the present disclosure is primarily amatter of surgeon preference for the particular surgical procedure to beperformed.

The lengths of the various portions of the construct 10 can likewisedepend, at least in part, on the other components with which theconstruct is used, the tissue through which it will be passed or coupledto, the lengths of the various portions of the construct, and the typeof procedure in which the construct is used. As illustrated in FIG. 1A,a length α of the loop 12 can be in the range of about 12.7 centimetersto about 50.8 centimeters, a length β of the coaxial region 14 can be inthe range of about 7.62 centimeters to about 50.8 centimeters, and alength γ of the tail 16 can be in the range of about 12.7 centimeters toabout 101.6 centimeters, and in one embodiment the length a of the loop12 is approximately 21.59 centimeters, a length β of the coaxial region14 is approximately 21.59 centimeters, and a length γ of the tail 16 canbe about 25.4 centimeters. There is no specific ratio for any of lengthsα, β, and γ, and thus in other embodiments the lengths α and β can bedifferent, and one or both of lengths α and β can be larger than lengthγ. It can be desirable for the length α of the loop 12 to be long enoughso that it can be disposed outside of a cannula when in use, asdescribed in greater detail below. This makes it easier for the surgeonto work with the construct 10, and to monitor it to insure noundesirable tangling of portions of the filament 20 occurs. For example,in some embodiments, the length α of the loop 12 can be at least about20.32 centimeters, or at least about 21.59 centimeters, or even longer.Similarly, it can be desirable for the length β of the coaxial region 14to be long enough so that the terminal end 20 b does not fall out of thevolume of the filament 20, and long enough so that when the coaxialregion is disassembled, as described in greater detail below, the twolimbs that result from the disassociation are long enough to be graspedby a surgeon outside of the cannulas. For example, in some embodiments,the length β of the coaxial region 14 can be at least about 7.62centimeters, at least about 15.24 centimeters, at least about 20.32centimeters, or even longer. A length of the filament 20 itself can bein the range of about 38.1 centimeters to about 203.2 centimeters, andin one exemplary embodiment it has a length of about 111.76 centimeters.

In embodiments in which the filament 20 is braided, the pick count ofthe braid can be adjusted to assist in receiving the terminal end 20 b.For example, the pick count for a portion of the filament 20 configuredto receive the terminal end 20 b to form the coaxial region 14 can beapproximately in the range of about 30 picks per 2.54 centimeters toabout 60 picks per 2.54 centimeters, and in one instance the pick countcan be about 40 picks per 2.54 centimeters. A person skilled in the artwill recognize that other pick counts can be used depending, at least inpart, on the size of the terminal end 20 b to be received, the type oftissue through which the coaxial region 14 will be disposed, and thevarious desired properties of the overall construct, such as the ease ofsliding a filament within the volume of the filament 20.

As shown in FIG. 2, the construct 10 can be coupled to a suture anchor80. The suture anchor 80 can have an internal cannulation 82 extendingthrough a portion thereof and one or more filament engagement features,such as the filament engagement feature 84 disposed at a distal end 80 dof the anchor 80. In the illustrated embodiment, the loop 12 extendsfrom one side of the anchor 80 and the terminal end 10 a, including atleast a portion of the tail 16, extends from the other side of theanchor 80. Although in the illustrated embodiment the coaxial region isdisposed on the same side as the loop 12, in other embodiments thecoaxial region 14 can be at least partially disposed on the same side asthe terminal end 10 a, at least because the construct 10 can generallybe configured to slide with respect to the filament engagement feature84 to move to various locations with respect to the anchor 80. Theanchor can also include one or more external fixation enhancements, suchas threads 86, for engaging bone in which the anchor can be disposed.

One skilled in the art will appreciate that a variety of suture anchortypes can be used in conjunction with the constructs provided herein,including both hard and soft anchors, and that the disclosure is notintended to be limited to the designs of anchors provided for herein.Some exemplary embodiments of anchors that can be used in conjunctionwith the constructs and related teachings provided for herein include aHealix Ti™ anchor, a Healix Advance™ anchor, a Healix Advance™ Knotlessanchor, a Versalok™ anchor, and a Gryphon™ anchor, each of which iscommercially available from DePuy Mitek, Inc., as well as anchorsdescribed in U.S. Patent Application Publication No. 2013/0296934, andU.S. patent application Ser. No. 13/623,429, entitled “Systems, Devices,and Methods for Securing Tissue Using Hard Anchors,” filed Sep. 20,2012, the content of which is incorporated by reference herein in theirentireties.

While FIG. 2 illustrates a single construct associated with the anchor80, in other embodiments more than one construct can be loaded onto theanchor 80. By way of non-limiting examples, FIG. 3A illustrates anembodiment in which constructs 10, 10′ are double-loaded onto a sutureanchor 80′, and FIG. 3B illustrates an embodiment in which constructs10, 10′, 10″ are triple-loaded onto the suture anchor 80′. The sutureanchor 80′ can include a filament engagement feature (not shown) aroundwhich each construct 10, 10′, 10″ can be disposed. As a result, theloops 12, 12′, and 12″ can be disposed on one side of the anchor 80′ andthe terminal ends 10 a, 10 a′, and 10 a″ including at least a portion ofthe tails 16, 16′, and 16″ can be disposed on an other side of theanchor 80′.

Each construct 10, 10′, 10″ disposed around the filament engagementfeature can be in a touching, side-by-side disposition. In otherembodiments one construct can be disposed over a portion of another asthey wrap around a portion of the filament engagement feature. The useof multiple constructs with one anchor can increase the resultingfootprint of the implant. Further, as the number of constructsassociated with the anchor 80′ increases, the benefits of the providedfor configurations are magnified. In particular, the suture managementbenefits are even more pronounced with two and three constructsassociated with the anchor 80′ than with one construct. As the number ofconstructs increase, the size of the constructs can remain the same, orthey can decrease to help allow more filaments to be attached to theanchor and used without interfering with the other filaments. By way ofnon-limiting example, in some exemplary embodiments of a singleconstruct or two constructs being associated with an anchor the filamentforming the construct(s) can be a #2 (about 22 gauge to about 24 gauge)Orthocord™ filament, and in some exemplary embodiments of threeconstructs being associated with an anchor the filament forming thethree constructs can be a #0 (about 26 gauge to about 27 gauge)Orthocord™ filament.

The use of multiple constructs can also enhance the type andeffectiveness of various tissue repair surgical procedures, includingthose discussed below and others known to those skilled in the art. Eachconstruct can have a unique identifier to assist the surgeon inidentifying a particular filament during the procedure. Examples ofunique identifiers include, but are not limited to, different colors,patterns, or surfaces to provide different tactile feels. Additionally,each construct 10 itself can have unique identifiers associated witheach terminal end, thus making it easier for a surgeon to know which endhas the loop 12 and which is the tail 16. Identifying the two differentends of a single construct can be helpful in allowing the surgeon toknow which end will serve as a post along which a collapsed Lark's Headcinch loop is distally advanced, as described in greater detail below.

The size of the anchor 80′ can depend on a variety of factors,including, by way of non-limiting example, the type and size of theconstructs with which it is used, the bone in which it will be disposed,and the type of procedure in which it will be used, but in someexemplary embodiments it can have an outer diameter in the range ofabout 3 millimeters to about 6 millimeters, and in one embodiment itsouter diameter can be about 4.75 millimeters. Further, although in theillustrated embodiments the constructs 10, 10′, and 10″ are associatedwith an anchor 80′, other types of implantation devices can also be usedin conjunction with the constructs 10, 10′, and 10″. Such devicesinclude, by way of non-limiting example, cortical buttons and otherstrands of suture filament. Alternatively, the construct 10 can be usedindependent of an anchor, for instance to help grasp or tie tissue andthe like, as described further below and in greater detail in U.S.Patent Application Publication No. 2013/0296931, the content of whichwas previously incorporated herein by reference.

Exemplary methods for using constructs of the type described herein arenow described in further detail. The methods described herein generallyrelate to attaching soft tissue, such as tendon 105, to bone, although aperson skilled in the art will recognize other types of procedures withwhich the constructs and the methods related to the same can be used.The embodiment illustrated in FIGS. 4A-4N is performed in a minimallyinvasive manner, e.g., arthroscopically, through a first cannula 100 anda second cannula 102 that are disposed through a patient's skin 104using techniques known to those skilled in the art. The use of multiplecannulas can help a surgeon manage filament during a surgical procedure,as well as any instruments used in conjunction with the procedure. Inthe illustrated embodiment the first cannula 100 is substantiallyaligned with the location at which the procedure is performed and servesas a working channel. A person skilled in the art will recognize otherways by which the procedures described herein can be performed,including through three or more cannulas, a single cannula, or throughno cannula at all. Further, other types of procedures, such as openprocedures, can be used in conjunction with the present disclosures.

As shown in FIG. 4A, a bone hole 108 can be formed in bone 106 usingtechniques known to those skilled in the art. The bone hole 108 can bedisposed at a location proximate to the location at which the tendon 105is to be attached. An anchor 80 and a suture construct 10 can then bepassed through the first cannula 100 and implanted in the bone hole 108using ordinary techniques, such as by using a driver to screw or tap theanchor into place. In the illustrated embodiment of FIG. 4B, theterminal end of the tail 16 extends from one side of the filamentengagement feature 84 and out of the cannula 100 and the loop 12 extendsfrom the other side of the filament engagement feature 84 and also outof the cannula 100. The construct 10 can be coupled to or otherwiseassociated with the anchor 80 prior to implantation, or it can be threadaround the filament engagement feature 84 after the anchor 80 has beenimplanted in the bone 106.

As shown in FIG. 4C, a portion of the construct 10 that includes theloop 12 can be moved to the second cannula 102. This allows foradditional visibility in the working channel, and also helps a surgeonmanage the two terminal ends 10 a, 10 b of the construct 10 so they donot become tangled and/or interchanged during portions of the procedure.Any technique known to those skilled in the art can be used to effectmovement of the tail 16, and any portion of the filament 20 for thatmatter. In some exemplary embodiments a tool sometimes referred to as asuture grasper can be used.

As shown in FIG. 4D, the tail 16 can be passed through the tendon 105 tobe attached to bone 106 and can be passed through the second cannula102. This results in an unobstructed view in the working channel foradditional steps in the procedure. While the tail 16 can be passedthrough tissue using a number of techniques known to those skilled inthe art, in some embodiments a suture passing device such as theEXPRESSEW II flexible suture passer, which is available from DePuyMitek, LLC, can be passed through the first cannula 100 and operated topass the tail 16 through the tendon 105. Furthermore, a tool such as asuture grasper can be used to move the tail 16 into the second cannula102 after it has been passed through the tendon 105.

In some procedures, including some described below with respect to otherillustrated embodiments, the loop 12 is not passed through tissue.However, one benefit afforded by the configuration of the presentconstruct 10 is that it can be easily passed through tissue whileminimizing an amount of trauma resulting from the same. In the presentembodiment, the loop 12 is passed through tissue, as shown the tendon105. Optionally, as shown in FIG. 4E, the loop 12 can be moved from thesecond cannula 102 to the first cannula 100 prior to passing the loop 12through tendon 105. Doing so can help with suture management and preventtangling of the filament 20 with itself or other objects disposed at ornear the surgical site. The loop 12 can be passed through the tendon 105and again back to the second cannula 102 using known techniques forpassing filament through tissue. The loop 12 can pass through the tendon105 easily because it is only the two strands of filament 20 that pressthrough the tendon 105. There are no additional suture managementcomponents, knots, or other obstructions associated with the loop 12.The configuration that results from passing the loop 12 through thetendon 105 and into the second cannula 102 is illustrated in FIG. 4F.

Both the loop 12 and the tail 16 can be returned to the first cannula100 for use in the working channel, as shown in FIG. 4G. A receivingopening 52 can then be formed in the loop 12. A number of differenttechniques can be used to form the receiving opening, but in oneexemplary embodiment, which is illustrated in FIG. 4H, a Lark's Headcinching loop 50 is formed from the filament 20 that forms the loop 12,with the Lark's Head cinching loop 50 being disposed at the distal end10 b of the construct 10. FIGS. 6A-6C, which are described in furtherdetail below, describe one exemplary embodiment for forming a Lark'sHead cinching loop, although a person skilled in the art will understandnumerous techniques that can be used to form a Lark's Head cinchingloop. Other types of configurations can also be used to form thereceiving opening without departing from the spirit of the presentdisclosure.

As shown in FIG. 4I, the tail 16 can be passed through the receivingopening 52 to form a collapsing loop 54 that captures the filamentengagement feature 84 and the tendon 105. The Lark's Head cinching loop50 can then be collapsed or dressed around the portion of the tail 16disposed therethrough, as shown in FIG. 4J. Further, tension can beapplied to the terminal end 10 a of the construct 10 by pullingapproximately in a direction C, thereby causing the collapsed Lark'sHead cinch loop 50 to slide distally toward the tendon 105 in a zip-linelike manner until the collapsed Lark's Head cinch loop 50 is adjacent tothe tendon 105, as shown in FIG. 4K. Alternatively, tension can beapplied to the terminal end 10 a of the construct 10 before the Lark'sHead cinch loop 50 is dressed and after the Lark's head cinch loop 50 isadjacent to the tendon, or some combination of the two actions can beused, such as partially dressing the Lark's Head cinch loop 50 beforezip-lining it toward the tendon 105. In some embodiments, a knot-pushingtool can be used to assist in advancing the collapsed Lark's Head cinchloop 50 toward the tendon 105. The collapsed Lark's Head cinch loop 50provides sufficient holding to maintain tension in the collapsing loop54. Further, the collapsed Lark's Head cinch loop 50 provides a wider,low profile configuration that can reduce trauma to the tendon. Moreparticularly, while the implant can be wider because of the two portionsof filament extending through the tissue, the distance that thecollapsed Lark's Head cinch loop 50 extends away from the tendon 105 issmaller than configurations previously relied upon for attaching tissueto bone. The configuration can also have a wide profile because portionsof the filament 20 are hollow, allowing the filament 20 to becomeflatter with respect to the tendon 105 in which it is disposed.

Advancing the Lark's Head cinch loop 50 toward the tendon 105 can resultin the coaxial region 14 being moved out of the tissue and out of thecannula, as shown in FIG. 4K. When the coaxial region 14 is out of thetissue and exposed outside of the cannula 100, it can be easier todisassemble the coaxial region 14 and to prevent portions of thefilament 20 from tangling with itself or other components associatedtherewith. A disassembled coaxial region is illustrated in FIG. 4L. Asdescribed above with respect to FIG. 1B, the second terminal end 20 bcan be untucked or pulled out of the volume of the filament 20 proximateto the opening 22. The resulting configuration is a pair of limbs 56, 58extending out of the first cannula 100 that can be used in a variety ofways to complete a tissue attachment procedure.

The compression afforded by the Lark's Head cinch loop 50 can hold thetendon 105 through which the construct 10 is passed at a desiredlocation. Nevertheless, in one instance, illustrated in FIG. 4M, thelimbs 56, 58 can assist in providing further security by being cinchedor otherwise tied together to secure the location of the collapsedLark's Head cinch loop 50, and thus the tendon 105, with respect to thebone 106. In the illustrated embodiment, a half-hitch 60 is formed bythe surgeon using the first and second limbs 56, 58. Tying an initialhalf-hitch creates a one-way lock that allows for further tightening ofthe collapsing loop 54, i.e., by distally advancing the collapsed Lark'sHead cinch loop 50, without expanding the loop, i.e., it prevents thecollapsed Lark's Head cinch loop 50 for moving proximally. In someembodiments, a second half-hitch 62 can be formed to lock the locationof the first half-hitch 60, thereby preventing advancement of thecollapsed Lark's Head cinch loop 50 in either the distal or proximaldirections. As shown in FIG. 4N, the limbs 56, 58 can be trimmedrelatively close to the collapsed Lark's Head cinch loop 50 andassociated half hitch(es) 60, 62 formed adjacent thereto, however, careshould generally be taken not to cut the limbs 56, 58 too close to thecollapsed Lark's Head cinch loop 50 so as not to affect the integrity ofthe collapsed Lark's Head cinch loop 50 and associated half hitch(es)60, 62.

In addition to the aforementioned low profile configuration that resultsfrom the described procedure and variations thereof, there are numerousother advantages associated with the construct 10 and its use insurgical procedures. For instance, the resulting strength of the endingconfiguration is as strong and/or stronger than existing configurationsknown in the art. This is particularly impressive given that it takes upless space with its low profile.

The strength of the construct 10 was tested by determining a failureload for the construct, i.e., the amount of force at which thecollapsing loop 54 expanded 3 millimeters or more. The tested constructwas formed from a #2 Orthocord™ filament and was disposed on a 9.5millimeter dowel pin. The collapsing loop 54 was formed from thefilament using techniques described herein. Accordingly, the Lark's Headcinch loop 50 was collapsed to form the collapsing loop 54 and twohalf-hitches were tied on top of the collapsed cinch loop 50 to lock thelocation of the cinch loop 50. The resulting collapsing loop 54 had twolimbs of the filament disposed adjacent to each other in a side-by-sideconfiguration on the dowel pin. Load was then progressively applied tothe collapsing loop 54 and an amount of expansion of the loop wasmeasured as the amount of load increased. Once the collapsing loopexpanded 3 millimeters or more, the amount of load applied was noted asthe failure load. During testing of the aforementioned constructconfiguration, the failure load for the #2 Orthocord™ filament when itwas coated with New Vicryl Coating was about 270 Newtons. The failureload for the #2 Orthocord™ filament when it was not coated with anadditional material was about 360 Newtons

Another benefit afforded by the side-by-side configuration is that ithelps reduce a tendency of the filament 20 to abrade or cut through thetissue, which can occur more readily when just a single filament extendsthrough the tissue. Still further, the configurations provided forherein are uncomplicated, and to the extent any knot tying is involved,such tying is quick and easy. This allows surgeons to perform moreconsistent procedures from patient-to-patient.

In some embodiments, rather than trimming the two tails 56, 58, they canbe used to associate a second anchor with the first anchor 80 to form adual-row repair. FIG. 5A represents one such configuration, which issometimes referred to as a double row spanned repair. As shown, thetails 56, 58 extend from the one or more half-hitches 60, 62 and towarda second anchor 80″ disposed in the bone 106 at a location proximate tothe first anchor 80. The second anchor 80″ can be disposed in the bone106 using techniques known to those skilled in the art, including byforming a bone hole 108″ in which the anchor 80″ can be disposed. Inthis embodiment, the second anchor 80″ can be a truly knotless anchor,such as a Healix Advance™ Knotless anchor or a Versalok™ anchor becauseof the use of the two tails 56, 58 and the anchor 80″ to secure thelocation of the collapsed Lark's Head cinch loop 50.

As shown, the limbs 56, 58 can be placed such that as the anchor 80″ isdisposed in the bone hole 108″, the tails 56, 58 can be pinched betweenan outer surface of the anchor 80″ and a wall of the bone hole 108″.Terminal ends 56t, 58t of the limbs 56, 58 can then be passed throughthe anchor 80″ and back out a top side 80a″ of the anchor 80″ forsubsequent use and/or removal. In the illustrated embodiment, the secondanchor 80″ is fully cannulated through a length thereof and does notinclude a filament engagement feature, while the first anchor 80 is alsofully cannulated through its length but does include a filamentengagement feature 84. A person skilled in the art will recognize that avariety of different anchor configurations can be used in conjunctionwith this surgical technique, and thus the illustrated embodiment of oneanchor having a filament engagement feature and a second anchor beingcannulated with no filament engagement feature is no way limits thescope of the present disclosure. Further, although in the illustratedembodiment the tails 56, 58 extend from the one or more half-hitches 60,62 formed adjacent to the Lark's Head cinch loop 50, in otherembodiments no half-hitches are formed and the location of the Lark'sHead cinch loop 50 is instead secured by applying tension to the tails56, 58. For example, driving the second anchor 80″ into the bone hole108″ and trapping the tails 56, 58 between the anchor 80″ and the bone106 can supply sufficient tension to secure the location of the Lark'sHead cinch loop 50, and thus the tendon 105 itself. Similarly, even aLark's Head cinch loop can be eliminated such that the tension suppliedto the tails 56, 58 by virtue of being pinched between the anchor 80″and the bone 106 can be sufficient to maintain a desired location inconjunction with performing a dual-row type repair. A person skilled inthe art will recognize a variety of other ways by which the constructsand techniques described herein can be used in conjunction with a dualrow type repair.

FIG. 5B illustrates an alternative embodiment of using a lateral rowanchor 80″ to help secure the location of the constructs 10, 10′ withrespect to the anchor 80′ of FIG. 3A. This embodiment is sometimesreferred to as a double row span procedure. As shown, tails and loops ofthe two constructs 10, 10′ can be passed through to a top side of thetissue 105 at locations M, N and P, Q, respectively, as shown. The tailsof the first construct 10, 10′ can then be passed through respectivereceiving openings 50, 50′ formed in the loops of the constructs 10, 10′the receiving openings 50, 50′ can be collapsed, and the receivingopenings 50, 50′ can be advanced toward the tissue 105 as shown usingtechniques previously described above. The coaxial regions of theconstructs 10, 10′ can be disassembled, resulting in limbs 56, 58extending from the collapsed receiving opening 50 of the construct 10and limbs 56′, 58′ extending from the collapsed receiving opening 50′ ofthe construct 10′. The limbs 56, 58 and 56′, 58′ can then be trappedbetween the anchor 80″ and bone 106 in a manner similar to as describedwith respect to FIG. 5A. In some embodiments, the receiving opening 50,50′ can be a Lark's Head cinch loop as described herein. Whilehalf-hitches can be used in conjunction with the Lark's Head cinch loopas described herein, the tension to the limbs 56, 58 and 56′, 58′supplied by the anchor 80″ can be sufficient to maintain the location ofthe constructs 10, 10′ with respect to the anchor 80′. Further, in otherembodiments, the loop itself can be the receiving openings 50, 50′ andno half-hitches or other knots can be associated therewith because thelocation of the constructs 10, 10′ with respect to the anchor 80′ can bemaintained by the tension supplied to the limbs 56, 58 and 56′, 58′ bythe anchor 80″.

FIGS. 6A-6C illustrate one exemplary embodiment for forming the Lark'sHead cinch loop 50, which is a process that can be performed inconnection with the formation of the receiving opening 52 as illustratedin FIG. 4H. As shown in FIG. 6A, the filament 20 can be foldedsubstantially in half at an approximate midpoint 20m of the filament 20,forming a first filament limb 51 and a second filament limb 53. Acentral portion of the filament, which includes the midpoint 50m, can befolded toward the first and second limbs 51, 53 and brought proximate tothe first and second limbs 51, 53, as shown in FIG. 6B. This results inthe formation of a first sub-loop 55 and a second sub-loop 57. A size ofthe sub-loops 55, 57, and a length of the remaining portions of thelimbs 51, 53 extending therefrom, can be adjusted as desired. Thesub-loops 55, 57 can then be folded back on themselves, for instance bygrasping a portion 51 p, 53 p of the limbs 51, 53 that are part of thesub-loops 55, 57 and pulling upward (as shown, “out of the page”). Thisresults in the configuration illustrated in FIG. 6C, which as shown isthe filament 20 having the Lark Head's cinch loop 50 formed therein withremaining portions of the first and second limbs 51, 53 extendingtherefrom. The Lark's Head cinch loop 50 defines the collapsiblereceiving opening 52, a size of which can be decreased by applying aforce in an approximate direction F to one or both of the limbs 51, 53extending from the loop 50, or by applying a force in an approximatedirection G to the opening 52. Likewise, a size of the opening 52 can beincreased by grasping near the midpoint 20 m of the filament 20 to holdthe portion where the fold is formed approximately stationary and thenapplying either a force in the approximate direction G to both of thelimbs 51, 53 extending from the cinch loop 50, or a force in theapproximate direction G to the opening 52.

A person skilled in the art will recognize other ways by which a Lark'sHead cinch loop can be formed. Similarly, a person skilled in the artwill be familiar with other types of cinch loop or knottedconfigurations, e.g., configurations having sliding knots, that can beformed from suture filaments, and will understand ways in which othertechniques can be adapted for use in a manner as the Lark's Head cinchloop is used in the present disclosure. The present disclosure is notlimited to use only with a Lark's Head cinch loop.

FIGS. 7A-7F illustrate another exemplary embodiment for using theconstruct 10 in a tissue repair procedure. Although not illustrated, asurgical opening can be formed through a patient's skin and one or morecannulas can be passed therethrough to create a surgical repair site ina manner similar to described above with respect to FIGS. 4A-4N andotherwise known to those skilled in the art. The cannula(s) is not shownfor ease of illustration. A bone hole 108 can be formed in bone 106using techniques known to those skilled in the art, with the bone hole108 located at a location proximate to the location at which the tissue,which is tendon 105 in the illustrated embodiment, is to be attached.Unlike the configuration described above, in the illustrated embodimentthe construct 10 is disposed through tissue prior to being associatedwith an anchor disposed in the bone 106. As shown in FIG. 7A, the tissueis passed through the tissue such that both the tail 16 and the loop 12extend proximally toward the surgeon for use during the procedure. Theconstruct 10 can be associated with the tendon 105 using a variety oftechniques, including by threading the tail 16 through the tissue from atop side 105 a to a bottom side 105 b, and then back again from thebottom side 105 b to the top side 105 a. In an alternative embodiment,both the tail 16 and the loop 12 can be passed through the tendon 105 toachieve the configuration illustrated in FIG. 7A.

The tail 16 can then be passed through the loop 12, as shown in FIG. 7B.Alternatively, as shown in FIG. 7C, the loop 12 can be formed into aLark's Head cinch loop 50 using techniques previously described, orothers known to those skilled in the art, and then the tail 16 can bepassed through the receiving opening 52 defined by the cinch loop 50. Ineither configuration, passing the tail 16 through the loop 12 orreceiving opening 52 results in the formation of a collapsing loop 54.As described above, the Lark's Head cinch loop 50 can be collapsed ordressed around the portion of the tail 16 disposed therethrough.Likewise, to the extent that the loop 12 is adjustable, a person skilledin the art would recognize ways by which the loop 12 could be collapsedaround the portion of the tail 16 disposed therethrough. As shown inFIG. 7D, tension can be applied to the terminal end 10 a of theconstruct 10 by pulling approximately in a direction C, thereby causingthe loop 12 (FIG. 7B) or Lark's Head cinch loop 50 (FIG. 7C) to slidedistally toward the tendon 105 in a zip-line like manner until the loop12 or Lark's Head cinch loop 50 is adjacent to the tendon 105. Thecollapsed loop 12 and the collapsed Lark's Head cinch loop 50 providesufficient holding to maintain tension in their respective collapsingloops 54.

The coaxial region 14 of the construct 10 can subsequently bedisassembled, as shown in FIG. 7E. More specifically, a second terminalend of the filament 20 can be untucked or pulled out of the volume ofthe filament 20 proximate to an opening of the filament 20, as describedabove with respect to FIG. 1B. The resulting configuration is a pair oflimbs 56, 58 that can be used in a variety of ways to complete a tissueattachment procedure. By way of non-limiting example, FIG. 7Fillustrates the limbs 56, 58 extending to an anchor 80′″ disposed in thebone hole 108 in a manner as described previously with respect to FIG.5. In an alternative embodiment, illustrated in FIG. 8, the limb 56 canextend from the collapsed Lark's Head cinch loop 50 associated with theanchor 80′″ (not shown) located in a medial or primary fixation row toan anchor 80 c located in a lateral row, while the limb 58 can extendfrom the collapsed Lark's Head cinch loop 50 to an anchor 80 d alsolocated in the lateral row. Tension can be applied to the limbs 56, 58by the respective anchors 80 c, 80 d, or using other techniques known tothose skilled in the art, thereby maintain a location of the collapsedreceiving opening with respect to the anchor 80′″. While as describedwith respect to FIG. 8 the Lark's Head cinch loop 50 is associated withan anchor, in other embodiments the collapsed Lark's Head cinch loop 50can be associated with the tissue 105 on its own, i.e., without ananchor, using techniques disclosed herein or otherwise known to thoseskilled in the art.

FIGS. 9-15 illustrate some further, non-limiting types of tissuesecuring procedures that can be performed using the constructs andrelated disclosures provided for herein. The constructs can lead toprocedures that are faster, easier, and more durable than existingtissue repair procedures.

FIG. 9 illustrates one exemplary embodiment of a single row repair. Asshown, two anchors 80′ are double-loaded such that they both include twoconstructs 10, 10′ coupled thereto. The anchors 80′ are disposed in bone106 using techniques known to those skilled in the art. The loop andtail of one of the constructs 10 associated with each anchor 80′ can bepassed through to a top side of the tissue 105 at locations M₁ and N₁ asshown. The tail can then be passed through a receiving opening 52 formedin the loop, the receiving opening 52 can be collapsed, and thecollapsed receiving opening 52 can be advanced toward the tissue 105using techniques described herein. Further, the tail of the otherconstruct 10′ can be passed through to a top side of the tissue 105 at alocation P₁ as shown, for engagement with the loop associated with theanchor 80′. The tail can then be passed through a receiving opening 52′formed in the loop, the receiving opening 52′ can be collapsed, and thecollapsed receiving opening 52′ can be advanced toward the tissue 105 asshown using techniques previously described above. The location P₁ issuch that when the tail and loop are coupled together via the receivingopening 52′, the combination of the tail and loop of the first construct80 is disposed between the tissue 105 and the combination of the tailand loop of the second construct 10′. As a result, the combination ofthe tail and the loop of the first construct 10 can serve as a rip stopor cruciate stitch to help prevent tissue tearing by the other construct10′.

FIG. 10 illustrates one exemplary embodiment of a lateral row anchorrepair using two anchors 80 a, 80 b disposed in bone 106 in a lateralrow, each anchor 80 a, 80 b having a single construct 10 a, 10 bassociated therewith, and two additional constructs 10 c, 10 d extendingfrom the medial or primary fixation row. In the illustrated embodimentthe third and fourth constructs 10 c and 10 d are double-loaded onto ananchor 80 c, although in other embodiments each construct can beassociated with its own anchor, or the constructs 10 c, 10 d can becoupled to tissue without use of an anchor using techniques describedherein or otherwise known to those skilled in the art. The anchors 80 a,80 b, 80 c are configured like the anchor 80 of FIG. 2, and theconstructs 10 a, 10 b, 10 c, and 10 d are configured like the construct10 of FIG. 2, but the addition of the letters “a,” “b,” “c,” and “d” areincluded for identification purposes of the separate implants.

As shown, the anchors 80 a, 80 b are disposed in the bone 106 in alateral row, with the constructs 10 a, 10 b each having a loop and atail as described herein. The loop for each construct 10 a, 10 b can beconfigured to receive portions of the third or fourth constructs 10 c,10 d, as well as the tail of its own construct 10 a, 10 b. For example,a Lark's Head cinch loop can form a receiving opening 52 a, 52 b in theloop to receive the third or fourth constructs 10 c, 10 d and therespective construct tail and collapse around them. Alternatively, theloop can have another collapsible configuration that is capable ofcollapsing around a construct 10 c, 10 d and the tail of the respectiveconstruct 10 a, 10 b of the loop.

In the illustrated embodiment, the loop and tail of the construct 10 ccan be passed through to a top side of the tissue 105 at locations M2and N2 as shown. Likewise, the loop and tail of the construct 10 d canbe passed through to a top side of the tissue 105 at locations P2 and Q2as shown. The tail of the respective construct 10 c, 10 d can then bepassed through its own receiving opening 52 c, 52 d formed in its loop,the receiving opening 52 c, 52 d can be collapsed, and the collapsedreceiving opening 52 c, 52 d can be advanced toward the tissue 105 usingtechniques described herein. The coaxial region of the tails of theconstructs 10 c, 10 d can be disassembled into limbs 56 c, 58 c and 56d, 58 d. Optionally, one or more half-hitches can be formed using thelimbs 56 c, 58 c and 56 d, 58 d. Regardless of whether any half-hitchesare formed, the limbs 56 c, 58 c, and 56 d, 58 d can be extended towardsthe lateral row anchors 80 a, 80 b. In the illustrated embodiment thelimbs 56 c, 58 c, and 56 d, 58 d are extended in a crossing manner suchthat the limbs 56 c, 58 c extend to the anchor 80 a that is on theopposite side of the medial anchor 80 c, and the limbs 56 d, 58 d extendto the anchor 80 b that is also on the opposite side of the medialanchor 80 d. A person skilled in the art will recognize that otherconfigurations for associating the limbs 56 c, 58 c and 56 d, 58 d withthe anchors 80 a, 80 b can also be used.

As shown, the receiving opening 52 a associated with the anchor 80 a canreceive the limbs 56 c, 58 c, as well as the tail of the construct 10 a,and then the receiving opening 52 a can be collapsed or dressed tocapture the limbs 56 c, 58 c and the tail. Likewise, the receivingopening 52 b associated with the anchor 80 b can receive the limbs 56 d,58 d, as well as the tail of the construct 10 b, and then the receivingopening 52 b can be collapsed or dressed to capture the limbs 56 d, 58 dand the tail. A pulling force can be applied to the respective tails,which in turn can pull the collapsed receiving openings 52 a, 52 b ontothe respective anchors 80 a, 80 b. The coaxial region of the tails ofthe constructs 10 a, 10 b can be disassembled and used to form one ormore half-hitches. While the half-hitches can set the location of thereceiving openings 52 a, 52 b with respect to the anchors 80 a, 80 b,the limbs 56 c, 58 c and 56 d, 58 d of the constructs 10 c, 10 d canstill be slid through the respective openings 52 a, 52 b. The limbs 56c, 58 c and 56 d, 58 d can be used to form one or more half-hitches toset the location of the limbs 56 c, 58 c and 56 d, 58 d to prevent themfrom sliding.

FIG. 11 illustrates one exemplary embodiment of using the construct 10and anchor 80 of FIG. 2 in a tissue repair procedure. As shown, theanchor 80 having the construct 10 associated therewith is implanted inbone 106 in a medial or primary fixation row. The tail 16 of theconstruct 10 passes through the tissue 105 to a top side of the tissueat a location M3 and the loop 12 of the construct 10 passes through thetissue 105 to a top side of the tissue at a location N3. The tail 16 ispassed through a portion of the loop 12, and is then extended to ananchor 80″″ disposed in the lateral row in the bone 106. Tension isapplied to the tail 16, and thus the rest of the construct 10, bytrapping the tail 16 between the anchor 80″″ and the bone 106. As aresult, the formation of a Lark's Head cinch loop and/or half-hitchescan be optional.

FIG. 12 illustrates another exemplary embodiment of using the construct10 and anchor 80 of FIG. 2 in a tissue repair procedure. In thisembodiment, a thicker footprint can be achieved by using a thickerfilament 20, such as a #5 Ethibond™ filament. As shown, the anchor 80having the construct 10 associated therewith can be implanted in amedial or primary fixation row. The loop and tail of the construct 10can be passed through tissue 105 to a top side of the tissue atlocations M4 and N4, and the tail can then be passed through thereceiving opening 52 formed by the loop, such as a Lark's Head cinchloop. The receiving opening 52 can be collapsed around the tail, andthen a coaxial region of the construct 10 can be deconstructed asdescribed herein. The limbs 56, 58 that result from the deconstructionof the coaxial region can extend side-by-side to an anchor in thelateral row for subsequent attachment. Because the filament 20 is of athicker variety, the configuration of the construct 10 can be of aribbon-like footprint.

FIG. 13 illustrates one exemplary embodiment of using the anchor 80′ inconjunction with the three constructs 10, 10′, and 10′ illustrated inFIG. 3B. In this embodiment, thinner filaments 20 can be used to moreeasily allow for all three constructs 10, 10′, 10″ to be operatedwithout tangling or other undesirable obstructions. As shown, the tailscan be passed through tissue 105 to a top side of the tissue atlocations M5, N5, and P5, to engage with the loops associated with theanchor 80″. The tails can then be passed through a receiving opening 52,52′, 52″ formed by the loops, such as Lark's Head cinch loops. Thereceiving openings 52, 52′, 52″ can then be collapsed around therespective tails. The coaxial region can be deconstructed and then thelimbs resulting therefrom can be used to tie one or more half-hitches tomaintain a location of the collapsed receiving openings 52, 52′, 52″using techniques described herein or otherwise known to those skilled inthe art. In some embodiments, a rip stitch 90 can be disposed laterallyacross a portion of the tissue 105 to receive the collapsed receivingopenings 52, 52′, 52″. The rip stitch 90 can prevent undesirable tearingdue to stress caused by the collapsed receiving openings 52, 52′, 52″.

FIG. 14 illustrates one exemplary embodiment for repairing a tear 109 intissue 105. In the illustrated embodiment, the construct 10, 10′ is usedin two different ways to repair the tear 109. In one instance, theconstruct 10 is used by itself, without any attachment to any anchor orother implant device. The tail 16 and the loop 12 can extend fromopposite sides of the tear 109 at locations M6 and N6 as shown. Then theconstruct 10 can be operated in a manner similar to as described hereinfor other embodiments. For example, a receiving opening can be formedfrom the loop 12, the tail 16 can be disposed in the receiving opening,and the receiving opening can be collapsed or dressed around the tail16. Tension can then be applied to the tail 16 to advance the collapsedreceiving opening against the tissue 105, and thus adjacent to the tear109. As the receiving opening is collapsed, the portions of tissue 106through which the tail 16 and loop 12 are disposed can be drawn towardseach other.

In the other instance, the construct 10′ is used in conjunction with ananchor (not shown) disposed in bone 106. The tail and the loop extendfrom opposite sides of the tear 109 at locations P6 and Q6 as shown.Then the construct 10′ is operated as described with respect to thefirst instance in FIG. 14. The illustrated embodiment shows thecollapsed receiving opening 52′ with the tail disposed therethroughadjacent to the tear 109 and one or more half-hitches formed therein tolock the location of the collapsed receiving opening 52′ with respect tothe tear 109. Using the construct 10′ with the anchor provides for asecure attachment of the torn tissue 105 to bone 106 while alsoproviding repair to the tear 109 itself. Use of the construct 10 withoutthe anchor can be used to help repair the tear 109 even withoutattaching to bone, for example in instances in which the tear is locatedtoo far away from the bone to effectively use an anchor.

FIG. 15 illustrates one exemplary embodiment of using the dual-loadedanchor 80′ of FIG. 3A in an instability repair involving a glenoid orhip 106′ and labral tissue 107. As shown, the anchor 80′ is implanted inthe hip 106′ using techniques known to those skilled in the art. Each ofthe two tails 16, 16′ are then passed from one side of the labral tissue107 to the other side. The loops 12, 12′ remain disposed on the sameside of the labral tissue as the anchor 80′. The tails 16, 16′ and loops12, 12′ are then operated using techniques described herein or otherwiseknown to those skilled in the art. For example, a collapsible receivingopening can be formed in the loop 12, 12′ and the receiving opening canreceive the tail 16, 16′. The tail 16, 16′ can then be operated toadvance the collapsed receiving opening toward the anchor 80′, which inturn draws the labral tissue 107 toward the hip 106′. The resultingcollapsed receiving opening can be held in place by some combination ofa Lark's Head cinching loop (if used to form the receiving opening forinstance), one or more half-hitches, or extending limbs from adisassembled coaxial region toward another anchor to apply tension tothe limbs.

One skilled in the art will appreciate further features and advantagesof the invention based on the above-described embodiments. Accordingly,the invention is not to be limited by what has been particularly shownand described, except as indicated by the appended claims. A personskilled in the art would be able to adapt the constructs, anchors, andtechniques provided for herein for suitable use with other combinationsof constructs, anchors, and techniques without departing from the spiritof the present disclosure. Further, although the constructs and methodsprovided for herein are generally directed to surgical techniques, atleast some of the constructs and methods can be used in applicationsoutside of the surgical field. All publications and references citedherein are expressly incorporated herein by reference in their entirety.

What is claimed is:
 1. A surgical construct formed from a suturefilament, comprising: a first terminal end of the filament, a secondterminal end of the filament, and an intermediate portion of thefilament disposed along at least a portion of a length extending betweenthe first and second terminal ends; a coaxial region formed by the firstterminal end being disposed within a volume of a portion of theintermediate portion; and a continuous, closed loop extending from afirst side of the coaxial region, the loop having a first end directlyadjacent to the first side of the coaxial region and a second, opposedend formed by a fold in the suture filament, wherein the second, opposedend of the loop is a first terminal end of the construct, and whereinthe second terminal end of the filament extends from a second side ofthe coaxial region and is a second terminal end of the construct.
 2. Theconstruct of claim 1, wherein a length of the coaxial region is at leastabout 15.24 centimeters.
 3. The construct of claim 1, wherein a lengthof the loop is at least about 20.32 centimeters.
 4. The construct ofclaim 1, wherein a length of the loop is configured to be adjusted bymoving the first terminal end of the filament with respect to thecoaxial region.
 5. The construct of claim 1, wherein a pick count of thecoaxial region is in the range of about 30 picks per 2.54 centimeters toabout 60 picks per 2.54 centimeters.
 6. The construct of claim 1,further comprising an anchor having a filament engagement feature at adistal end thereof, wherein the suture filament engages the filamentengagement feature such that the first terminal end of the constructextends from one side of the filament engagement feature and the secondterminal end of the construct extends from an opposite side of thefilament engagement feature.
 7. A surgical repair method, comprising:inserting an anchor having surgical filament associated therewith inbone in proximity to detached soft tissue, the surgical filament havinga first portion with a loop formed therefrom, a second portion thatincludes a terminal end, and a coaxial region formed between the firstand second portions by disposing a portion of the filament into its ownvolume; passing the terminal end of the second portion of the filamentthrough a portion of the detached soft tissue; forming a snare in theloop of the first portion of the filament after the anchor has beeninserted in bone in proximity to detached soft tissue; passing theterminal end of the second portion through the snare; collapsing thesnare to engage the soft tissue; advancing the collapsed snare distallyto bring the tissue into proximity with the bone; and deconstructing thecoaxial region by removing the portion of the filament from the volumeof the filament in which it was disposed.
 8. The method of claim 7,further comprising passing the loop through a portion of the detachedsoft tissue before forming the snare in the loop.
 9. The method of claim8, wherein the anchor has a second surgical filament associatedtherewith, the second surgical filament having a first portion with aloop formed therefrom, a second portion that includes a terminal end,and a coaxial region formed between the first and second portions bydisposing a portion of the filament into its own volume, the methodfurther comprising: passing the terminal end of the second portion ofthe second filament through a portion of the detached soft tissue;passing the loop of the second filament through a portion of thedetached soft tissue; after passing the loop of the second filamentthrough a portion of the detached soft tissue, forming a snare in theloop of the first portion of the second filament; passing the terminalend of the second portion of the second filament through the snare ofthe second filament; collapsing the snare of the second filament toengage the soft tissue; advancing the collapsed snare of the secondfilament distally to bring the tissue into proximity with the bone;deconstructing the coaxial region of the second filament by removing theportion of the second filament from the volume of the second filament inwhich it was disposed, wherein deconstructing the coaxial region of thefirst filament results in a first limb and a second limb extending fromthe collapsed snare of the first filament, and deconstructing thecoaxial region of the second filament results in a first limb and asecond limb extending from the collapsed snare of the second filament;attaching the first and second limbs of the first filament and the firstand second limbs of the second filament to a second anchor; and applyingtension to the first and second limbs of the first and second filamentsto secure a location of the limbs with respect to the second anchor. 10.The method of claim 9, wherein applying tension to the first and secondlimbs of the first and second filaments to secure a location of thelimbs with respect to the second anchor further comprises inserting thesecond anchor into bone with the first and second limbs of the first andsecond filaments being disposed between an outer wall of the anchor andthe bone.
 11. The method of claim 9, wherein the locations of the firstand second limbs of the first and second filaments with respect to thesecond anchor are secured without tying a knot in either of the first orsecond filaments.
 12. The method of claim 8, wherein the anchor has asecond surgical filament associated therewith, the second surgicalfilament having a first portion with a snare formed therein, a secondportion that includes a terminal end, and a coaxial region formedbetween the first and second portions by disposing a portion of thefilament into its own volume, the method further comprising: passing theterminal end of the second portion of the second filament through aportion of the detached soft tissue; passing the terminal end of thesecond portion of the second filament through the snare of the secondfilament; collapsing the snare of the second filament to engage the softtissue; and advancing the collapsed snare of the second filamentdistally to bring the tissue into proximity with the bone, the firstfilament being disposed between the collapsed snare of the secondfilament and the soft tissue.
 13. The method of claim 7, furthercomprising tying at least one locking knot with the filament at alocation that is proximate to the collapsed snare to secure a locationof the filament with respect to the tissue.
 14. A surgical repairmethod, comprising: inserting an anchor having a surgical constructassociated therewith in bone in proximity to detached soft tissue, thesurgical construct having a first terminal end and a second terminalend; passing the first terminal end through a portion of the detachedsoft tissue; passing the second terminal end through a portion of thedetached soft tissue; forming a Lark's Head cinch loop in the secondterminal end of the surgical construct after the first and secondterminal ends have been passed through portions of the detached tissue,the Lark's Head cinch loop defining a receiving opening; passing thefirst terminal end of the construct through the receiving opening;collapsing the receiving opening of the Lark's Head cinch loop; andadvancing the collapsed Lark's Head cinch loop distally to bring thetissue into proximity with the bone.
 15. The method of claim 14, whereinthe surgical construct is formed from a surgical filament having a firstterminal end, a second terminal end, and an intermediate portionextending therebetween, with the first terminal end of the constructbeing the first terminal end of the filament, and the second terminalend of the construct having a loop formed by the second terminal end ofthe filament being disposed in a portion of the intermediate portion ofthe filament.
 16. The method of claim 15, further comprising: removingthe second terminal end of the filament from the intermediate portion ofthe filament after collapsing the receiving opening of the Lark's Headcinch loop; and tying at least one knot with the filament at a locationthat is proximate to the collapsed Lark's Head cinch loop to secure alocation of the filament with respect to the tissue.
 17. The method ofclaim 15, wherein the anchor has a second surgical construct associatedtherewith, the second surgical construct being formed from a secondsurgical filament having a first terminal end, a second terminal end,and an intermediate portion extending therebetween, with a firstterminal end of the second construct being the first terminal end of thesecond filament, and a second terminal end of the construct having aloop formed by the second terminal end of the second filament beingdisposed in a portion of the intermediate portion of the secondfilament, the method further comprising: passing the terminal end of thesecond construct through a portion of the detached soft tissue; passingthe second terminal end of the second construct through a portion of thedetached soft tissue; forming a Lark's Head cinch loop in the secondterminal end of the second construct after the first and second terminalends of the second construct have been passed through portions of thedetached tissue, the Lark's Head cinch loop of the second constructdefining a receiving opening; passing the first terminal end of thesecond construct through the receiving opening of the second construct;collapsing the receiving opening of the Lark's Head cinch loop of thesecond construct; advancing the collapsed Lark's Head cinch loop of thesecond construct distally to bring the tissue into proximity with thebone; removing the second terminal end of the first filament from theintermediate portion of the first filament after collapsing thereceiving opening of the Lark's Head cinch loop of the first construct;removing the second terminal end of the second filament from theintermediate portion of the second filament after collapsing thereceiving opening of the Lark's Head cinch loop of the second construct,wherein removing the second terminal ends of the first and secondfilaments from their respective intermediate portions results inrespective first and second limbs extending from each of the collapsedLark's Head cinch loops; attaching the first and second limbs of thefirst filament and the first and second limbs of the second filament toa second anchor; and applying tension to the first and second limbs ofthe first and second filaments to secure a location of the limbs withrespect to the second anchor.
 18. The method of claim 17, whereinapplying tension to the first and second limbs of the first and secondfilaments to secure a location of the limbs with respect to the secondanchor further comprises inserting the second anchor into bone with thefirst and second limbs of the first and second filaments being disposedbetween an outer wall of the anchor and the bone.
 19. The method ofclaim 17, wherein the locations of the first and second limbs of thefirst and second filaments with respect to the second anchor are securedwithout tying a knot in either of the first or second filaments.
 20. Themethod of claim 15, wherein the anchor has a second surgical constructassociated therewith, the second surgical construct having a firstterminal end and a second terminal end, the second terminal end having asnare formed therein, the method further comprising: passing the firstterminal end of the second construct through a portion of the detachedsoft tissue; passing the first terminal end of the second constructthrough the snare of the of the second construct; collapsing the snareof the second construct to engage the soft tissue; and advancing thecollapsed snare of the second construct distally to bring the tissueinto proximity with the bone, the first construct being disposed betweenthe collapsed snare of the second construct and the soft tissue.